title: Possible fatal acetaminophen intoxication with atypical clinical presentation.
abstract: Acetaminophen or paracetamol, a commonly used over-the-counter analgesic, is known to elicit severe adverse reactions when taken in overdose, chronically at therapeutic dosage or, sporadically, following single assumptions of a therapeutic dose. Damage patterns including liver damage and, rarely, acute tubular necrosis or a fixed drug exanthema. We present a case of fatal acetaminophen toxicity with postmortem blood concentration 78 μg/mL and unusual clinical features, including a visually striking and massive epidermolysis and rhabdomyolysis, disseminated intravascular coagulation and myocardial ischemia. This case is compared with the most similar previous reports in terms of organ damage, clinical presentation, and cause of death. We conclude that a number of severe patterns of adverse effects to acetaminophen are emerging that were previously greatly underestimated, thus questioning the adequacy of the clinical spectrum traditionally associated with acetaminophen intoxication and leading to the need to review this spectrum and the associated diagnostic criteria.
authors.affiliation: Institute of Legal Medicine Catholic University, School of Medicine, L.go F. Vito, 1 00168, Rome, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: De-Giorgio
authors.affiliation: Institute of Legal Medicine Catholic University, School of Medicine, L.go F. Vito, 1 00168, Rome, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Lodise
authors.affiliation: Institute of Legal Medicine Catholic University, School of Medicine, L.go F. Vito, 1 00168, Rome, Italy.
authors.forename: Marcello
authors.initials: M
authors.lastname: Chiarotti
authors.affiliation: Department of Public Health, Forensic Medicine Section, Cagliari University, Km 4.500 SS. 554 Bivio per Sestu, 09042, Monserrato, Italy.
authors.forename: Ernesto
authors.initials: E
authors.lastname: d'Aloja
authors.affiliation: Institute of Pathologic Anatomy, School of Medicine, Catholic University, L.go F. Vito, 1 00168, Rome, Italy.
authors.forename: Arnaldo
authors.initials: A
authors.lastname: Carbone
authors.affiliation: Department of Social Medicine & Department of Vascular Medicine, University of Amsterdam, Academic Medical Center. Meibergdreef 9, 1105 Az, Amsterdam, The Netherlands.
authors.forename: Luca
authors.initials: L
authors.lastname: Valerio
mesh_terms: D000082:Acetaminophen / Q000097:blood / Q000506:poisoning*; D058186:Acute Kidney Injury / Q000139:chemically induced; D018712:Analgesics, Non-Narcotic / Q000097:blood / Q000506:poisoning*; D004211:Disseminated Intravascular Coagulation / Q000139:chemically induced* / Q000473:pathology; D004820:Epidermolysis Bullosa / Q000139:chemically induced* / Q000473:pathology; D005260:Female; D049429:Forensic Pathology; D053593:Forensic Toxicology; D006801:Humans; D007668:Kidney / Q000473:pathology; D008099:Liver / Q000473:pathology; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000473:pathology; D017202:Myocardial Ischemia / Q000139:chemically induced* / Q000473:pathology; D012206:Rhabdomyolysis / Q000139:chemically induced* / Q000473:pathology; D012867:Skin / Q000473:pathology
chemical_list: D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen
keywords: acetaminophen; epidermolysis; forensic pathology; forensic science; forensic toxicology; intoxication; paracetamol; rhabdomyolysis; skin necrosis